Variables on a Theme -VOAT

Speech disorders are fairly common in MS. Speech patterns are controlled by many areas in the brain, especially the brainstem. Lesions (damaged areas) in different parts of the brain can cause several types of changes in normal speech patterns. They range from mild difficulties to severe problems that make it difficult to speak and be understood. Medically, speech disorders are called dysarthrias.

Long Pauses

One pattern that is commonly associated with MS is so-called scanning speech. Scanning dysarthria produces speech in which the normal “melody” or speech pattern is disrupted, with abnormally long pauses between words or individual syllables of words.

Slurred or Nasal Sounding Speech

People with MS may also slur words. This is usually the result of weakness and/or incoordination of the muscles of the tongue, lips, cheeks and mouth. Other speech problems include nasal speech, which sounds as though the person has a cold or nasal obstruction.

Dysarthrias are commonly associated with other symptoms caused by lesions in the brainstem. These include tremor, head shaking or incoordination.

Therapists Can Evaluate and Help Improve Speech

Many people can be aided by a speech/language pathologist, who can evaluate and help to improve speech patterns, enunciation and oral communication in general.

If a person with MS becomes unable to speak, there are many assistive devices available. These range from alphabet cards to hand-held communicators that print out a tape, to computers that respond to eyeblinks.

Speech/Language Pathologists Treat Swallowing Problems

Many persons with dysarthria also have dysphagia (difficulty in swallowing). Speech therapists are trained to evaluate, diagnose and relieve these problems. Changing the types of food and their consistencies can be helpful for some. People who can no longer swallow without choking can receive adequate nutrition and fluids through feeding tubes place.

Trigeminal neuralgia has to be one of the worst symptoms that people with multiple sclerosis (MS) experience. A couple of readers have written to me about this symptom and said that there were no words to describe the intensity of their pain. It is one of the types of pain described as “neurogenic pain” or “primary pain,” meaning it is the direct result of the disease process of multiple sclerosis, caused by demyelination and lesions on specific nerves.

What Does It Feel Like?

Trigeminal neuralgia, often called tic doloureux (French for “painful twitch”), is perhaps the most intensely painful MS-related symptom. It can be described most commonly as:
occurring in the lower part of the face (often triggered by chewing, drinking or brushing one’s teeth)
intense, sharp pain
like an electrical jolt
usually the most intense pain is short-lived (from a few seconds to up to two minutes), but can result in a more constant burning or aching
However, it should be noted that it can also have the following characteristics:

extending as far as the ear, and often mistaken for the pain of an ear infection
can be triggered by loud sounds
How Common Is It?

Trigeminal neuralgia is fairly rare, with only 4% of people with MS experiencing this kind of pain. However, people with MS are 400 times more likely than the general population to have an episode of trigeminal neuralgia.
What Causes It?

Trigeminal neuralgia pain can be brought on by chewing or touch. It is caused by lesions on the trigeminal nerve, which is also called the fifth cranial nerve. (The 12 cranial nerves emerge directly from the brain instead of from the spinal cord.) The trigeminal nerve controls the muscles needed for chewing, and is responsible for most facial sensation.
How Severe Can It Get?

Trigeminal neuralgia can get so severe and so distressing that it can require hospitalization and intravenous painkillers. It can interfere with a person’s intake of food and fluids and require that these also be supplemented intravenously. Some people may require surgery for this symptom. However, it is rare that it ever gets this severe.
Due to the intensity of this symptom, anxiety and fear about the possibility of it recurring can cause unnecessary suffering and interfere with daily life, even when the symptom is not present.

Additional Points/Information

Tends To Be Episodic: Each “bout” with trigeminal neuralgia usually lasts a couple of weeks. However, this symptom tends to recur and can happen as often as every couple of months. Some people will go years between episodes of this symptom. Unfortunately, as time passes, time between episodes gets shorter.

Hold Off On the Root Canals: Given the location and nature of the pain associated with trigeminal neuralgia, it is often mistaken for dental pain. This could lead to unnecessary (and irreversible) procedures like tooth extractions, root canals and even procedures to reposition the jaw. Make sure that you see your neurologist if you are experiencing this kind of pain, especially before undergoing any kind of drastic dental work.

Appears Early: Trigeminal neuralgia tends to be one of the first symptoms of multiple sclerosis for those who experience it.

Constipation is characterized by infrequent bowel movements (usually fewer than two bowel movements per week), or by frequent straining to void fecal matter.

Constipation is very common among people with MS. In general, poor diet (including consuming less than 20 grams of fiber per day), lack of physical activity, and depression all affect the digestive system. Medications and supplements may also contribute to constipation.

With MS, constipation may be caused by an interruption of impulses to the brain that signal the need for a bowel movement. MS may also prevent pelvic floor muscles from relaxing. These muscles are used to help void fecal matter. Also, MS may block the natural increase in activity of the colon following meals.

2. Bowel Incontinence

Bowel incontinence is the loss of voluntary bowel control. A person suffering from bowel incontinence may not be able to reach the bathroom fast enough. The most common causes include long-term constipation, severe diarrhea, stress, hemorrhoids, nerve or muscle damage, and overuse of laxatives.

3. Diarrhea

Diarrhea is frequent, loose, or watery stools. It is sometimes the result of allergies or sensitivity to spicy foods or dairy products, contaminated water or food, a change in activity level, or viral, bacterial, and parasitic infections.

Diarrhea can also be the signal of another problem. If it becomes frequent or continual, see your doctor. In some cases, your doctor may recommend that you see a doctor who specializes in treating bowel problems (gastroenterologist).

How Can I Maintain Regular Bowel Movements With Multiple Sclerosis?

Increase your fluid intake. Try to drink six to eight glasses of water daily. If you’re having urinary problems linked to multiple sclerosis it may be tempting to cut back on your fluid intake, but this makes constipation worse. Lack of water may harden the stool, making it more difficult to pass. And increased pressure from the stool on parts of the urinary system may actually increase bladder problems. Drink something hot as the first beverage in the morning, such as hot water or hot apple cider or drink ½ to 1 cup of prune juice in the morning to stimulate a bowel movement.

Increase your fiber intake. Eating plenty of fresh fruits and vegetables and whole grain breads and cereals is the best way to increase the amount of fiber you eat. Add 2 to 4 tablespoons of unprocessed wheat bran to foods and drink plenty of liquids (liquids help bran to be effective). Try bran sprinkled over hot or cold cereal, casseroles, or mixed with applesauce, pancake batter, pudding, muffin batter, milk shakes, or cookie dough. Your doctor may also recommend that you take a fiber supplement such as Metamucil.

Try to maintain regularity. Establish a regular time for emptying the bowels. Plan trips to the bathroom immediately after meals since eating is a natural stimulus for having a bowl movement. Try to wait no more than two to three days between bowel movements.

Medically speaking, fatigue is not the same thing as tiredness. Tiredness happens to everyone — it is an expected feeling after certain activities or at the end of the day. Usually you know why you are tired and a good night’s sleep solves the problem.

Fatigue is a daily lack of energy; unusual or excessive whole-body tiredness not relieved by sleep. It can be acute (lasting a month or less) or chronic (lasting from one to six months or longer). Fatigue can prevent a person from functioning normally and affects a person’s quality of life.

According to the National Multiple Sclerosis Society, 80% of people with MS have fatigue. MS-related fatigue tends to get worse as the day goes on, is often aggravated by heat and humidity, and comes on more easily and suddenly than normal fatigue.

What Can I Do About MS-Related Fatigue?

The best way to combat fatigue related to your MS is to treat the underlying medical cause. Unfortunately, the exact cause of MS-related fatigue is often unknown, or there may be multiple causes. However, there are steps you can take that may help to control fatigue. Here are some tips:

1. Assess your personal situation.

Evaluate your level of energy. Think of your personal energy stores as a “bank.” Deposits and withdrawals have to be made over the course of the day or the week to balance energy conservation, restoration, and expenditure. Keep a diary for one week to identify the time of day when you are either most fatigued or have the most energy. Note what you think may be contributing factors.

Plan ahead and organize your work. For example, change storage of items to reduce trips or reaching, delegate tasks when needed, and combine activities and simplify details.
Schedule rest. For example, balance periods of rest and work and rest before you become fatigued. Frequent, short rests are beneficial.

Pace yourself. A moderate pace is better than rushing through activities. Reduce sudden or prolonged strains. Alternate sitting and standing.

Practice proper body mechanics. When sitting, use a chair with good back support. Sit up with your back straight and your shoulders back. Adjust the level of your work. Work without bending over. When bending to lift something, bend your knees and use your leg muscles to lift, not your back. Do not bend forward at the waist with your knees straight. Also, try carrying several small loads instead of one large one, or use a cart.

Limit work that requires reaching over your head. For example, use long-handled tools, store items lower, and delegate activities whenever possible.
Limit work that increases muscle tension.
Identify environmental situations that cause fatigue. For example, avoid extremes of temperature, eliminate smoke or harmful fumes, and avoid long hot showers or baths.
Prioritize your activities. Decide what activities are important to you, and what could be delegated. Use your energy on important tasks.

Many people with MS experience some degree of tremor, or uncontrollable shaking. It can occur in various parts of the body.

There are several types of tremor:

Intention tremor—generally is greatest during physical movement; there is no shaking when a person is at rest. The tremor develops and becomes more pronounced as the person tries to grasp or reach for something, or move a hand or foot to a precise spot. This is the most common and generally most disabling form of tremor that occurs in people with MS.
Postural tremor—generally is greatest when a limb or the whole body is being supported against gravity. For example, a person who has a postural tremor will shake while sitting or standing, but not while lying down.
Resting tremor—generally is greatest when the body part is at rest and is diminished with movement. More typical of Parkinson’s disease than MS.
Nystagmus—produces jumpy eye movements.
Tremor occurs because there are plaques—damaged areas—along the complex nerve pathways that are responsible for coordination of movements. People with MS who have tremors may also have associated symptoms such as difficulty in speaking (dysarthria) or difficulty in swallowing (dysphagia)—activities that are governed by many of the same pathways involved in coordinating movement.

Tremor is One of the Most Difficult MS Symptoms to Treat

Tremor is considered by physicians and other health professionals to be one of the most difficult symptoms to treat. To date, there have been no reports of consistently effective drugs for tremor. Varying degrees of success have been reported with agents such as: the anti-tuberculosis agent, isoniazid (INH); the antihistimines Atarax® and Vistaril® (hydroxyzine); the beta-blocker Inderal® (propranolol); the anticonvulsive medication Mysoline® (primidone); a diuretic Diamox® (acetazolamide); and anti-anxiety drugs Buspar® (buspirone) and Klonopin® (clonazepam).

Weights and other devices can also be attached to a limb to inhibit or compensate for tremors. An occupational therapist is the health professional who can best advise about assistive devices to aid in the management of tremor.

More recently, deep brain stimulation (using electrodes implanted surgically into various brain areas) has been shown to be effective for the management of tremor in Parkinson’s disease. This has also been tried in MS patients (with varying degrees of success) although, at the moment, this therapeutic approach should be regarded as experimental.

Tremor can have significant emotional and social impact, especially when people choose to keep to themselves rather than be embarrassed by tremor. Isolation can lead to depression and further psychological problems. A psychologist, social worker, or counselor may be able to help a person with MS deal with these issues and become more comfortable in public.

Controversy continues over the role of alcohol or tetrahydro-cannabinol (THC), the active ingredient in marijuana, in treating tremor. Only small studies have been done, characterized by conflicting results. Marijuana remains a controlled substance under current policies of the U.S. Drug Enforcement Agency.

Everybody has a headache occasionally; however, people with multiple sclerosis (MS) are much more prone to migraine-like or cluster headaches than people in the general population. While the cause of most headaches is a mystery, some headaches in people with MS can be caused by lesions, depression or specific medications that they are taking. You should see your doctor for: Any type of unusual headache, a headache that keeps recurring, or one that lasts for a long time.
Note: Stay up-to-date on multiple sclerosis with my weekly newsletter.

What Do MS-Related Headaches Feel Like?

Headaches that are directly associated with MS have been described as:
Migraines

These seem to be more common in people with relapsing-remitting MS. They can be described as:

Often preceded by an aura (blurry or distorted vision signaling that a headache is about to begin) or prodrome symptoms (including fatigue, hunger or anxiety)
Throbbing on one or both sides of the head
Can be accompanied by sensitivity to light or sound
Typically accompanied by nausea, vomiting or loss of appetite
Residual pain and discomfort often follow headaches
Lasting from 4 to 12 hours
Cluster

Cluster headaches have the following characteristics:

May begin as a severe burning or stinging sensation on one side of the nose or deep in one eye
Pain peaks rapidly
Feels like electric shocks or “explosions” in or behind the eye
Only on one side of the face
Comes on without warning (unlike many migraines)
Tend to recur at the same time every day (often soon after falling asleep), usually for a period of several weeks
Can cause eye to water, nose to run or eyelid to droop
Pain completely resolves after headache (until next headache)
Lasting from 15 minutes to 3 hours
Tension-Type

These headaches are the most common in the general population, and can be described as follows:

Rarely causing severe pain, more often moderate or mild
Constant, band-like aching or squeezing sensation
Pain is either right over the eyebrows or encircling the head
Comes on gradually
Can happen any part of the day, but usually occurs in the latter part of the day
Lasting from 30 minutes to all day
How Common Are Headaches in People with MS?

Up to 58 percent of people with MS experience chronic or recurring headaches, compared to 16.5 percent of the general population. Of course, almost everyone (over 90 percent of people, MS or not) gets occasional headaches.

Sensory symptoms–also called sensory disturbances–are often the first signs of multiple sclerosis. Some people with MS have described these sensations as “pins and needles,” itching, burning, numbness or stabbing pains. One or several sensory symptoms of MS can appear in conjunction with other symptoms such as fatigue, muscle, bladder and bowel problems. MS is a neurological disease caused by demyelination, or damage to the myelin, the protective sheath that surrounds nerve fibers. Damage can also occur to the nerve fibers themselves. Damaged nerve fibers send erroneous signals between the brain, spinal cord and other parts of the body, and are the cause of sensory symptoms.
Optic Neuritis
Optic neuritis becomes apparent in the early stages of MS and affects about one-third of people who develop MS. Poor signals to the optic nerve can result in blurred or doubled vision, pain during eye movement, or the eye’s inability to properly follow an object. Serious cases can result in partial or complete loss of vision, which might be reversible.

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Neuralgia
Neuralgia, also called neuropathic pain, is pain without an apparent cause. Neuropathic pain can be a burning, itching or electrical shock sensation.
Trigeminal Neuralgia
Trigeminal neuralgia refers to neuropathic pain occurring on facial nerves on the lower part of the face and is one of the most painful sensory symptoms. Sometimes triggered by chewing or other facial movements, it has been described as an electric shock or an intense jab of pain that can last for a few seconds to a few minutes.
Anaesthesia
Anaesthesia, another common symptom in MS, refers to numbness or a complete loss of sensation.
Paraesthesia
Paraesthesia refers to tingling, buzzing, burning, skin crawling, vibration sensations and partial numbness. Paraesthesia is one of the most common sensory symptoms in MS and can occur anywhere on the body.
L’Hermitte’s
L’Hermitte’s is a type of paraesthesia characterized by short-lasting sensations of electrical buzzing, tingling, partial numbness and electrical shocks. L’Hermitte’s is sometimes triggered by movement of the neck.
Proprioceptive dysfunction
Proprioceptive dysfunction, also called sensory ataxia, is the loss of a sense of body awareness. This symptom can negatively affect an individual’s balance.
Pruritis
Pruritis (itching), also called dysesthetic itching, is a sudden bout of intense itching sensations that generally goes away quickly. It is one of the least common among the MS sensory symptoms.

Numbness of the face, body or extremities (arms and legs) is one of the most common symptoms of MS. Often it’s the first symptom experienced by those eventually diagnosed with MS. The numbness may be mild or so severe that it interferes with the ability to use the affected body part. For example, a person with very numb feet may have difficulty walking. Numb hands may prevent writing, dressing, or holding objects safely.

Caution Advised Regarding Eating and Hot Objects

People with MS who have severe facial numbness should be very careful when eating or chewing, as they may unwittingly bite the inside of their mouth or tongue. People with numbness over other parts of the body should be careful around fires, hot water and other sources of heat, as they may suffer a burn without realizing it.

There are no medications to relieve numbness. Fortunately, however, most instances of numbness are not disabling, and tend to remit on their own. In very severe cases, a neurologist may prescribe a brief course of corticosteroids, which often can temporarily restore sensation.

Dizziness is a common symptom of MS. People with MS may feel off balance or lightheaded. Much less often, they have the sensation that they or their surroundings are spinning — a condition known as vertigo.

These symptoms are due to lesions—damaged areas—in the complex pathways that coordinate visual, spatial, and other input to the brain needed to produce and maintain equilibrium.

Consult a physician when dizziness or vertigo becomes bothersome or lasts a long time. Usually, the symptoms respond to an anti motion-sickness drug such as meclizine (Antivert®, Bonine®, or Dramamine®), the newer skin patches that deliver scopolamine, or the anti-nausea drug ondansetron (Zofran®). In very severe cases of dizziness or vertigo, a short course of corticosteroids.

Disorders of the Middle Ear Can Also Cause Dizziness

Other conditions that may cause dizziness include middle ear inflammation and benign tumors of the acoustic nerve that connects the ear and the brain.

Optic neuritis usually affects one eye, although it may occur in both eyes simultaneously. Optic neuritis symptoms may include:

Pain. Most people who develop optic neuritis experience eye pain that’s worsened by eye movement. Pain associated with optic neuritis usually peaks within several days.

Vision loss. The extent of vision loss associated with optic neuritis varies. Most people experience at least some temporary reduction in vision. If noticeable vision loss occurs, it usually develops over the course of hours or days, and may be worsened by heat or exercise. Vision loss may be permanent in some cases.

Loss of color vision. Optic neuritis often affects the perception of colors. You may notice that the colors of objects, particularly red ones, temporarily appear “washed out” or less vivid than normal.

Flashing lights. Some people with optic neuritis report seeing flashing or flickering lights.

The signs and symptoms of optic neuritis may be indications of an autoimmune disorder called multiple sclerosis. In 15 to 20 percent of people who eventually develop multiple sclerosis, optic neuritis is their first symptom.

When to see a doctor

Eye conditions can be serious. Some may cause you to permanently lose your vision and some are associated with other serious medical problems. Contact your doctor in the following situations:

New symptoms. Anytime you have eye pain or notice a change in your vision, make an appointment to see your doctor.

Worsening symptoms. If you have optic neuritis and experience new eye pain, worsening vision or symptoms that don’t improve with treatment, see your doctor.

Unusual symptoms. If you have unusual symptoms, including numbness or weakness in one or more limbs, which may be an indication of a neurological disorder, see your doctor.-Mayo Clinic

Dysphagia – Difficulty Swallowing

Problems Swallowing as a Symptom of Multiple Sclerosis

It seems like swallowing would just be second nature, not something we have to think about in order to do safely. However, swallowing is a complicated process that involves all sorts of muscle coordination and feedback to and from the brain through certain nerves and neural pathways. Multiple sclerosis (MS) can damage any of these nerves as well as the area of the brain responsible for coordinating swallowing, the brainstem. This can lead to swallowing difficulties, called dysphagia.
What Do MS-Related Swallowing Problems Feel Like?

Dysphagia includes many different problems with the swallowing process, even those that don’t seem directly related to swallowing food, including:
Difficulty chewing
Coughing while eating or immediately afterwards
Excessive saliva or drooling
Choking
Food sticking in the throat
A weak, soft voice
Feeling that it is hard to swallow food or move it to the back of the mouth
Aspiration, meaning food or drink is going down the windpipe into the lungs
Vomiting food back up
How Common Are MS-Related Swallowing Problems?

Between 30 and 40 percent of people with MS experience swallowing problems at some time. However, for many people with MS-related dysphagia, these changes are so subtle that they may not be aware of them, besides experiencing the occasional coughing fit after something “goes down the wrong way.”
What Causes MS-Related Swallowing Problems?

Several different factors can contribute to swallowing problems, but the main cause of dysphagia are lesions in the part of the brain that controls swallowing (primarily the brainstem) or the nerves that provide feedback to the brain.
Dysphagia can also be caused or made worse by lack of saliva or dry mouth.